Beyond psychotherapy

To meet the vast unmet
demand for services,
psychologists are seeking
alternatives to traditional
one-on-one therapy.

By
Rebecca A. Clay

January 2012, Vol 43, No. 1

Print version: page 46

If psychologist David C. Mohr, PhD, has his way, smartphone users may soon be able to turn to their devices for help. He has already developed a prototype that relies on sensors in the phones to track where users are and what they’re doing. If the phone realizes that its owner has been sitting at home alone on a Saturday night, for example, it can take action, pinging the individual with a suggestion to call a friend or get out of the house. If the person follows through on his or her behavioral goals, the phone sends a congratulatory note.

The information is then provided back to patients so they can see the patterns in their lives and how certain actions or inactions can lead to their mood being better or worse, says Mohr, who directs the Center for Behavioral Intervention Technologies and is a professor of preventive medicine at Northwestern University. “Although this is very preliminary work, the mobile phone offers tremendous opportunities to engage patients in their environments when they are encountering difficulties,” says Mohr. “Behavioral intervention technologies begin to change the way we think about behavioral interventions.”

Mohr is not the only one who is exploring innovative ways to get psychological help to everyone who needs it. He and other psychologists are promoting greater use of telephone- and Internet-based interventions, peers and other nonprofessionals and self-help approaches, plus more emphasis on prevention efforts that could stop problems even before they begin. The reason? There’s just not enough psychotherapy to go around.

“At any given point, approximately 25 percent of individuals in the U.S. — children, adolescents and adults — meet criteria for a psychiatric disorder,” says Alan E. Kazdin, PhD, a psychology professor at Yale University. “And approximately 70 percent of individuals in need of psychological services do not receive them.”

Simply training more psychologists will not solve the problem, Kazdin emphasizes. For one thing, psychologists are typically concentrated in wealthy, urban areas, leaving large swaths of the country unserved. And many people do not have the time, transportation or financial means to take advantage of traditional psychotherapy.

“This is not a person power problem,” says Kazdin. “Even doubling the workforce would not do very much.”

Psychology for the masses

What is needed instead, Kazdin and co-author Stacey L. Blase of Yale argue in a 2011 paper in Perspectives in Psychological Science, is a “rebooting” of psychotherapy. While one-onone psychotherapy will always have a valued place, they say, the discipline needs to supplement it with an entire portfolio of new models for delivering interventions. Focused on both prevention and treatment of mental and substance abuse disorders, this portfolio could change how care gets delivered, who delivers it and where it takes place. Possibilities include the use of media, self-help approaches, technology, laypeople and new settings for interventions.

“We are walking around with one tool,” says Kazdin of psychotherapy. “We love this hammer, whether it is a Freudian hammer or a cognitive-behavioral hammer. The trouble is you do not build a house with just a hammer.”

Trends in the health-care system are only going to increase the challenges of providing care to all who need it, says Katherine C. Nordal, PhD, executive director of APA’s Practice Directorate. Health-care reform will give 32 million more Americans health-care coverage, she points out.

“This will increase the burden on the caregiving system within the mental health arena,” she says. “We’re going to have to think in new ways and deliver treatment in new ways.”

Part of the answer will be in finding new ways of using technology, she says. That’s one of the reasons APA, the APA Insurance Trust and the Association of State and Provincial Psychology Boards launched a task force in 2011 that will develop guidelines for telepsychology practice.

Marc S. Atkins, PhD, a professor of psychology in psychiatry at the University of Illinois at Chicago, agrees. He argues that psychologists should attack the nation’s unmet mental health needs the same way epidemiologists and others attack disease outbreaks like the H1N1 virus.

In a 2011 commentary on Kazdin and Blase’s paper in Perspectives in Psychological Science, Atkins and co-author Stacy L. Frazier, PhD, of the Florida International University propose a comprehensive three-tiered public health approach. It begins with health promotion efforts aimed at the general public; offers outreach, screening and interventions for those at high risk of mental health problems; and then provides intensive treatment for those who need it.

“We need a paradigm shift,” says Atkins. Instead of overfocusing on the most intensive type of service, he says, psychologists should focus more on prevention. “If we do a good job at health promotion, we reduce the need for treatment,” he says.

Atkins and Frazier’s own work in schools and beyond exemplifies this prevention-minded approach. In a collaboration with the Chicago park system described in a 2007 paper in Administration and Policy in Mental HealthandMental Health Services Research, for example, they consulted with park staff on how to engage kids in activities, support good behavior, coach and build skills. The goal? To ensure that after-school and summer programs promote mental health for children in poor, urban neighborhoods.

Atkins points to the TripleP Positive Parenting Program suite of parenting interventions as an example of the threetiered model in action. In a 2008 paper in the Journal of Family Psychology, Positive Parenting Program creator Matthew R. Sanders, PhD, of the University of Queensland, explains how the program evolved from an effective home-based, individually administered training program for parents of disruptive preschoolers in Australia to a comprehensive public health program that aims to teach better parenting skills to the general public around the world.

The Triple P interventions begin with television, radio, electronic and print media messages aimed at raising the general public’s awareness of parenting issues and encouraging participation in parenting programs. For parents who are interested in parenting information or have specific concerns about their children’s development or behavior, the next level up is help from primary-care practitioners, teachers, child care staff and others who can provide information, advice, training or consultations during routine well-child health-care visits, teacher meetings or similar venues. More intensive training is reserved for parents who need it the most.

Alternatives to one-on-one therapy

Much of the research has focused on finding new ways to reach individuals who are at risk of developing problems and those who already have them.

Behavioral intervention technologies, such as those that deliver care via the Internet or mobile phones, are one key strategy, says Mohr. In addition to solving the access problem, these interventions can also help individuals overcome barriers related to stigma. “A lot of patients anecdotally have told us during debriefing interviews that they really liked these kinds of interventions and would never go see a therapist,” says Mohr.

Computer programs for depression and other disorders, which typically teach principles of cognitive-behavioral therapy or some other evidence-based treatment, can work well for many people, says Mohr. That’s especially so if the interventions include a human touch — such as emails or quick phone calls — to help keep users on track and prevent attrition.

In a 2010 paper in the Journal of Medical Internet Research, for instance, Mohr and colleagues found that an Internet intervention for depression in which people logged in to a selfmonitoring website and also received email and telephone support had a substantial impact on depression. At baseline, 81 percent of participants met criteria for major depressive episodes — a number that had dropped to just 24 percent at the eight-week point of the intervention. The program’s attrition rate of less than 10 percent is not only lower than other Internet studies, which typically have attrition rates of 35 percent to 90 percent, but also lower than the 25 percent to 50 percent attrition rate seen in face-to-face psychotherapy.

Now Mohr is seeking ways to provide that supplemental social support even more cost-effectively. One idea is to harness the power of online social networks to increase people’s adherence to Internet interventions by engineering in principles of what Mohr calls “supportive accountability.” Say a person is supposed to log in to the intervention a certain number of times. “If a patient’s network of peers can see a patients’s goals and their log-in activity and the patient values his or her peers, the patient will be more likely to meet his or her log-in goals,” says Mohr.

In another line of research, Mohr and psychologist Albert “Skip” Rizzo, PhD, of the University of Southern California are exploring ways of creating computerized versions of interpersonal interactions once thought to require the presence of a live therapist. They are developing programmable virtual humans with whom users can role-play interpersonal skills. Existing solely online, these “online instantiations of humans” could play the role of a therapist who helps users practice assertiveness or other interpersonal skills in the safety of a virtual environment, Mohr explains.

Mohr is also looking at how to make sure each individual gets the right treatment. “The effects are reasonable for Internet treatment, but probably not as strong as face-to-face therapy,” he says. “While we got large results in our trial, it was an initial field trial, and those typically have larger effects.” A 2009 meta-analysis of Internet interventions published in Cognitive Behaviour Therapy showed smaller result sizes, he points out.

As a result, Mohr says, psychologists might use Internetbased interventions for clients who respond to them and save more intensive and costly face-to-face or over-the-phone psychotherapy for those who do not.

Some people may not need the minimal contact such interventions involve but can instead help themselves, says T. Mark Harwood, PhD, a private practitioner in West Chicago and co-author of “Self-Help in Mental Health: A Critical Review” (2010, Springer).

Self-help includes books, 12-step programs, online support groups, Internet-based programs and the like. While these approaches can be part of or even the main focus of therapy, they can also be used on their own by people whose problems aren’t severe. (Self-help isn’t for everyone, Harwood emphasizes, which is why he recommends that would-be self-help users seek an evaluation from a therapist first to make sure they’re good candidates for a primarily solo self-help approach.)

Of course, there are some approaches with no empirical support behind them, either because the evidence doesn’t support them or because they simply haven’t been studied yet. But, Harwood says, there is ample evidence indicating that some self-help approaches can be as effective as therapy itself. He cites as an example a 2008 study in Acta Psychiatrica Scandinavica that found that a self-help approach called cognitive self-therapy was not only as effective as therapistadministered treatment but much more cost-effective.

Still, there’s some resistance to self-help approaches among psychologists, says Harwood. He doesn’t think that should be the case. After all, he says, in addition to helping individuals working on their own, self-help can demystify and destigmatize psychological interventions. That may make working with an expert more palatable should the need arise in the future, he says.

One organization that’s already embracing alternatives to traditional psychotherapy is the Department of Veterans Affairs. Faced with a flood of service men and women returning from Iraq and Afghanistan — an estimated one third or more with mental health problems — the nation’s largest health-care system is using all sorts of innovative strategies for getting evidence-based treatment to veterans. These include assessment and treatment via videoconferencing, self-help via smartphone technology and the use of lay people like fellow veterans to deliver care.

Such options allow access to care to patients who live too far away from VA facilities and give veterans a choice about how to access care, says Associate Director Denise M. Sloan, PhD, of the Behavioral Science Division at the National Center for PTSD at the VA Boston Healthcare System. These alternative options can help patients overcome concerns about confidentiality and the stigma associated with seeking help that are prevalent in the military culture. And these strategies have the potential to deliver services to large numbers of people quickly and efficiently.

“The more options, the more people you can reach,” says Sloan.

New roles for psychologists?

Should psychologists worry that they’re being replaced by computer programs or individuals without doctoral training? Absolutely not, says Kazdin.

In fact, he says, psychology risks being left behind in an evolving health-care system if the discipline fails to embrace new ways of getting care to those who need it. The physical health-care realm is already moving in this direction, he points out.

Take the developing world’s fight against HIV/AIDS, for example. “They have enormous needs that cannot be met by doctors and nurses, but they can be met,” says Kazdin, citing the World Health Organization’s 2008 report Task Shifting: Rational Redistribution of Tasks Among Health Workforce Teams. If psychology digs in and insists that psychotherapy is the only way to get help, says Kazdin, the health system will simply move on.

Some psychologists think that “we’re going to outsource psychotherapy to Bangalore,” says Mohr. “But people want psychotherapy; it’s been demonstrated to be effective, and it’s going to continue to have an important — and probably central — place in the mental health care system.”

By offering other avenues for receiving care, says Mohr, the field could treat greater numbers of patients, allocating more expensive and less abundant one-on-one services to those who are in greater need and who do not respond to less intensive approaches.

Of course, determining who would benefit from less intensive approaches is key, a point that University of Arizona psychology professor Varda Shoham, PhD, and National Institute of Mental Health Director Thomas R. Insel, MD, make in another 2011 commentary on Kazdin and Blase’s piece in Perspectives in Psychological Science. While applauding the goal of reaching more people, they worry that increased use of technology and similar approaches may not make much of an impact on alleviating mental illness.

What’s needed, they argue, is better knowledge about who needs more intensive interventions and who could benefit from simplified interventions, plus a national research agenda that puts these questions on center stage. “In the absence of such knowledge,” they write, “we risk treatment decisions guided by accessibility to resources rather than patient needs — the very problem Kazdin and Blase aim to solve.”

Practitioners will also have new roles. In addition to providing traditional psychotherapy to the subset of patients who need it, psychologists will need to promote self-help, peer support, Internet-based interventions and other less intensive options, says Steven D. Hollon, PhD, a psychology professor at Vanderbilt University.

“Someone is going to have to train. Someone is going to have to supervise. Someone is going to have to develop systems. Who better than psychologists?” he says.

For Hollon, the prospect of an expanded array of service delivery options is exciting. And it would help American psychology catch up to its counterparts in the United Kingdom and other places where such approaches are already in widespread use.

“Psychology defines itself as a discipline that pays attention to the data and the evidence,” says Hollon. “We’ve changed many times over the course of our history. We’re a hardy weed species that always does well.”